NUR7202 – Fall 2013 Wright State University – Miami Valley School of Nursing and Health

1. Diagnosis, Prevention and Management of: acute pharyngitis, otitis media, sinusitis, conjunctivitis, corneal abrasion NUR7202 – Fall 2013 Wright State University – Miami Valley School of Nursing and Health

2. Group Members • Sarah Bunch BSN, RN, CEN • Jessica Gutsjo BSN, RN, CCRN • Michelle Lozano BSN, RN • Jamie McGuire BSN, RN

3. Objectives • Describe the pathologic process and etiology of acute pharyngitis, otitis media, sinusitis, conjunctivitis, and corneal abrasion. • Describe the signs and symptoms acute pharyngitis, otitis media, sinusitis, conjunctivitis, and corneal abrasion including differential diagnoses of each disease • Identify appropriate diagnostic testing for each disease • Identify evidence-based management of each disease including relevant contraindications, complications, and/or adverse reactions. • Provide rationale for health promotion activities and follow up

4. Acute Care of Pharyngitis Pharyngitis

5. Definition An infection or irritation of the pharynx and/or tonsils Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.

6. Pathophysiology • A bacteria or virus invades the pharyngeal mucosa and causes a localized inflammatory response • Other viruses can cause irritation of the pharyngeal mucosa secondary to nasal secretions Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.

7. Pathophysiology cont. Tintinalli, J., & Stapczynski, J. (2011). Tintinalli's emergency medicine : a comprehensive study guide / editor-in-chief, Judith E. Tintinalli ; co-editors, J. Stephan Stapczynski ... [et al.]. New York : McGraw-Hill, c2011.

8. Prevalence • Frequency • Approximately 30 million cases of pharyngitis are diagnosed annually • Pharyngitis accounts for over 10% of all office visits to primary care and 50% of outpatient antibiotic use • Viruses are the most common cause of acute pharyngitis • Age • Streptococcal infection occurs predominantly in patients between the ages of 5 and 18 years. • Pharyngitis in patients under 3 years old is uncommon but possible; it is nearly always due to viral etiologies. • Genetics • Individuals with a positive family history of rheumatic fever have a higher incidence of rheumatic complications if streptococcal infections are untreated.

9. Streptococcus pyogenes is the most significant bacterial agent causing pharyngitis in both adults and children • Group A Streptococcal infection (Streptococcus pyogenes) (100x Magnification) Harrison, T. R., & Longo, D. L. (2013). Harrison's manual of medicine. New York: McGraw-Hill Medical.

10. Symptoms Features suggestive of GAS as causative agent - bacterial • #1 Sore throat – most common symptom • Sudden onset and varying duration • Odynophagia and dysphagia • May need to be admitted for IV fluids and IV antibiotics • Fever • Headache • Abdominal pain • Nausea/vomiting • The individual may report contact with individuals diagnosed with GAS or rheumatic fever. • A history of rheumatic fever may be reported and is important in selecting appropriate treatment • Patient 5-15 years of age • Present in winter or early spring

11. Symptoms Features suggestive of viral origin Features suggestive of either viral or bacterial origin Neck pain Rhinorrhea Nasal congestion Arthralgia and/or joint stiffness Lymphadenopathy Dyspnea Chills Malaise • Diarrhea • Cough • Hoarseness • Coryza

12. Differential Diagnosis: GAS

13. Differential Diagnosis • Mycoplasma • Chlamydia trachomatis • Herpetic stomatitis • Gonococcal pharyngitis • Primary HIV infection • Diphtheria • Lemierre syndrome • Behcet syndrome • Kawasaki disease • Hand-foot-and-mouth disease • Oropharyngeal cancer or candidiasis • Influenza • Toxic shock syndrome • Apthous ulcers

14. Physical Assessment Features suggestive of GAS as causative agent - bacterial Features suggestive of viral origin Conjunctivitis Characteristic exanthems & enanthems • Tender, enlarged anterior cervical nodes • Tonsillopharyngeal erythema and/or exudates • Soft palate petechiae • Uvulitis • Scarlatiniform rash • Fever

16. Diagnostic Tests • Lab testing is not indicated in all patients with pharyngitis • All adults should be screened for (the four classic symptoms of GAS): • A history of fever • Lack of cough • Pharyngotonsillar exudates • Tender anterior cervical adenopathy • None or one of these findings should not be tested or treated for GAS The “Centor Criteria”

17. Pelucchi, C., Grigoryan, L., Galeone, C., Esposito, S., Huovinen, P., Little, P., , & Verheij, T. (2012). Guideline for the management of acute sore throat. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, 18 Suppl 1, 1-28. doi:10.1111/j.1469-0691.2012.03766.x

18. Diagnostic Tests cont.

19. Diagnosis Algorithm Esherick, J. S., Clark, D. S., & Slater, E. D. (2012). Current practice guidelines in primary care 2012. New York: McGraw-Hill Medical.

20. Treatment • Analgesics • Acetaminophen: • children: 10-15 mg/kg orally every 4-6 hours when required, maximum 90 mg/kg/day • adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day • Ibuprofen: • children: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day • adults: 400-800 mg orally every 6-8 hours when required, maximum 3200 mg/day • Local anesthetics • Lidocaine oronasopharyngeal solution – topical (oral) spray: • children and adults: 5% - apply 1 spray to affected area, then wait >1 minute and spit; may repeat up to 4 times daily • Benzocaine • Gargling with salt water • Antibiotic treatment should be reserved for patients with confirmed pharyngitis and not based on clinical diagnosis alone • Use of corticosteroids • Antibiotic therapy of GAS accelerates resolution by 1-2 days if initiated within 2-3 days of symptom onset

21. Group A Streptococcus (GAS) pharyngitis FOCUS IS TO TREAT GROUP A BETA-HEMOLYTIC STREPTOCOCCUS INFECTION TO PREVENT RHEUMATIC SEQUELAE • #1Penicillin or Amoxicillin • penicillin V potassium: • children ≤27 kg: 250 mg orally two to three times daily for 10 days • children >27 kg and adults: 500 mg orally two to three times daily for 10 days • penicillin G benzathine: • children ≤27 kg: 600,000 units intramuscularly as a single dose • children >27 kg and adults: 1.2 million units intramuscularly as a single dose • *Use if worried about PO compliance • amoxicillin: • children: 50 mg/kg/day orally given in 2 divided doses for 10 days, maximum 1000 mg/day • adults: 875 mg orally twice daily for 10 days • Amoxicillin should be avoided when concomitant infectious mononucleosis is suspected • Penicillin allergy: Macrolide, cephalosporin, or Clindamycin • GAS resistance to macrolides has been reported • azithromycin: • children: 12 mg/kg orally once daily for 3 days, maximum 500 mg/day • adults: 500 mg orally once daily for 3 days • clarithromycin: • children: 15 mg/kg/day orally given in divided doses every 12 hours for 10 days, maximum 500 mg/day • adults: 250 mg orally twice daily for 10 days • #1 erythromycin: • children: 25-50 mg/kg/day orally given in 4 divided doses for 10 days, maximum 2000 mg/day • adults: 250-500 mg orally four times daily for 10 days • cephalexin: • children: 25-50 mg/kg/day orally given in divided doses every 12 hours for 10 days, maximum 1000 mg/day • adults: 500 mg orally twice daily for 10 days • cefadroxil: • children: 30 mg/kg/day orally given in 1-2 divided doses for 10 days, maximum 1000 mg/day • adults: 1000 mg/day orally given in 1-2 divided doses for 10 days • clindamycin: • children: 20 mg/kg/day orally given in divided doses every 8 hours for 10 days, maximum 1800 mg/day • adults: 300-600 mg orally every 8 hours for 10 days • Doxycycline and trimethoprim/sulfamethoxazole are ineffective • Antibiotic prophylaxis in individuals with a history of rheumatic fever is recommended to decrease the risk of recurrence of rheumatic fever • Goal: prevent acute rheumatic fever, reduce the severity and duration of symptoms, and prevent transmission

22. Treatment: Rheumatic Fever

23. Treatment: Mononucleosis/EBV • About 1/3 of patients with infectious mononucleosis have secondary streptococcal tonsillitis, requiring treatment • Avoid Ampicillin • Supportive care • May require IV fluids and IV pain medication • A dose of PO of IV steroid may be administered • Splenomegaly: risk factors and symptoms of splenic rupture should be given • Rest is a frequent recommendation • Avoidance of strenuous physical activity in the initial 3 to 4 weeks of illness is desirable in light of the potential for splenic rupture • IVIG may be used in patients with immune thrombocytopenia. • Primary Options • prednisone: • children: 1-2 mg/kg/day orally • adults: 30-60 mg/day orally • immune globulin (human): • children and adults: consult specialist for guidance on dose

24. AGACNP Formulary • The AGACNP can prescribe all drugs discussed for the treatment of Acute Pharyngitis!! (except immune globulin) • Analgesics: Acetaminophen & Ibuprofen • Local anesthetics • Penicillin or Amoxicillin • Macrolides, Cephalosporins, or Clindamycin • Prednisone • Immune globulin • Physician Initiated OR Physician Consult • Must be noted on the standard care arrangement with the collaborating physician Ohio Board of Nursing (2012). The formulary developed by the Committee on Prescriptive Governance. Retrieved from http://www.nursing.ohio.gov/PDFS/AdvPractice/10-21-13_Formulary.pdf

25. Complications • Rheumatic fever • Low likelihood • Glomerulonephritis • Low likelihood • Peritonsillar abscess • Low likelihood • Otitis media • Low likelihood • Mastoiditis • Low likelihood • Sinusitis • Low likelihood • Bacteremia • Low likelihood • Pneumonia • Low likelihood

26. Health Promotion • Antibiotic use increases the risk of an antibiotic resistant infection • Symptoms should improve within 3 or 4 days • No need for bed rest or isolation • However close contacts who have symptoms of GAS pharyngitis or who have had rheumatic fever or post-streptococcal glomerulonephritis previously should be tested • Aspirin should be avoided in children because of its association with Reye syndrome • Children may return to school or daycare after taking antibiotics for at least 24 hours. • Hand-washing! • Cover mouth with coughing!

27. Prevention • Hand-washing! • Antibiotic prophylaxis is for GAS is in individuals with a history of rheumatic fever • No vaccine to prevent GAS pharyngitis!

28. Outcomes • Antibiotic therapy of GAS pharyngitis results in a decrease of symptom intensity and duration, and prevents the long-term complication of rheumatic fever • Symptom resolution is within a few days • Infected individuals are not immune to reinfection • Complications of viral pharyngitis are extremely uncommon • Symptoms usually go away within 7 to 10 days

29. Follow-up • There is no need to confirm successful antibiotic treatment after antibiotic therapy • EXCEPT for patients with: • A history of rheumatic fever • Infection due to an outbreak of GAS strains causing rheumatic fever or poststreptococcal glomerulonephritis. • If pharyngitis symptoms have not improved after 3 to 4 days alternate diagnoses should be considered.

30. Acute Care of Otitis Media Otitis Media

31. Pathophysiology • Bacterial or viral infection • Pathogens from the nasopharynx pass into the middle ear • Most frequent pathogens identified: • Streptococcus pneumoniae • Haemophilus influenzae • Moraxella catarrhalis • Viruses • Respiratory syncytial virus (RSV), rhinoviruses, influenza, adenoviruses • Congestion/dysfunction of the eustachian tube • Purulent material formation • Middle ear cleft • Pneumatized mastoid air cells • Petrous apex

32. Anatomy of the Ear

33. AOM vs OME • Acute Otitis Media • Middle ear effusion • Acute inflammation • Symptoms • otalgia • drainage from the ear • irritability • fever • hearing difficulty • problems with balance • Otitis Media with Effusion • Middle ear effusion with no other symptoms

34. Prevalence • Predominantly a pediatric diagnosis • Due to changes in ear anatomy with aging • 50-84% by age 3 have had AOM • 3-15% of adults

35. AOM and CSOM incidence rate, HI prevalence and mortality estimates for the year 2005, by WHO areas. Monasta L, Ronfani L, Marchetti F, Montico M, et al. (2012) Burden of Disease Caused by Otitis Media: Systematic Review and Global Estimates. PLoS ONE 7(4): e36226. doi:10.1371/journal.pone.0036226 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036226

36. Global AOM and CSOM incidence rate, HI prevalence and mortality estimates for the year 2005, by WHO age groups. Monasta L, Ronfani L, Marchetti F, Montico M, et al. (2012) Burden of Disease Caused by Otitis Media: Systematic Review and Global Estimates. PLoS ONE 7(4): e36226. doi:10.1371/journal.pone.0036226 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0036226

37. Signs & Symptoms • Major Presenting Complaint: • Otalgia • May be Associated With: • Fever • Otorrhea • Hearing Loss • Rarely Associated With: • Tinnitus • Vertigo • Nystagmus

38. Signs & Symptoms • Tympanic membrane: • May be Bulging or Retracted • May appear Red • Inflammation • May appear White/Yellow • Fluid in the middle ear • Pneumatic Otoscopy • Generally demonstrates impaired mobility

39. Pneumatic Otoscopy • http://www.youtube.com/watch?v=FqSCfqoCNiI • http://www.youtube.com/watch?v=eD5gLRHkmIs

40. Differential Diagnosis • Eustachian Tube Dysfunction • Patulous Eustachian Tubes • Eustachian Tube Obstruction • Eustachian Tube Salpingitis • Otitis Media with Effusion • Chronic Otitis Media • Tympanosclerosis • Foreign Body • Cholesteatoma • Bullous Myingitis • Nasopharyngeal Cancer • Mastoiditis • TMJ Dysfunction • Referred Pain • Pharyngitis • Sinusitis • Tooth Pain

41. Physical Assessment • Subjective report form the patient • Otoscopy • Bulging tympanic membrane • Pneumatic otoscopy • Tympanic membrane movement • Tympanometry

42. Diagnostic Tests • No “Gold Standard” test • Middle ear aspirate for culture • Bacterial and viral

43. Treatment of AOM • Amoxicillin 875 mg BID x 10 days or Amoxicilin 500 mg, 2 tabs BID x 10 days • If allergic to amoxicillin: Azithromycin 30 mg/kg x 1 dose • If no improvement after 3 days of starting treatment consider changing to: Augmentin ES 875/125 mg BID x 10 days • If significant symptoms remain after treatment consider: Rocephin IM/IV 1-2 gm daily x 1-3 days

44. Treatment • If perforation of tympanic membrane: • Cortisporin otic 4 drops in affected ear, 3 times a day for 7 days • For pain: • OTC analgesics such as tylenol or motrin can be recommended • Decongestants and antihistamines have not been shown to improve outcomes

45. AGACNP Formulary

46. Complications • Perforation • Mastoiditis • Facial nerve paresis • Labyrinthitis • Meningitis • Hydrocephalus • Abscess

47. Health Promotion and Prevention • Hib vaccine • Pneumococcal vaccine • Smoking cessation • Hand washing

48. Outcomes • Most will recover fully • Within 4 weeks • Most hearing loss will improve as symptoms resolve

49. Follow-up • If patient has symptomatic relief no follow up is required • If no relief of symptoms • Re-evaluate in 6 weeks • consider more extensive work-up to rule out other potential causes • Computed Tomography (CT) scan • Refer to otolaryngology

50. Acute Care of Sinusitis Sinusitis